Medics on the move: enterprise mobility in Asia's hospitals

Friday, 3 September 2010

Healthcare

By Jianggan Li | 23 October 2008

Ask what Dr Low Cheng Ooi, Chairman of the Medical Board of Singapore’s Changi General Hospital (CGH) would like to get his hands on during working hours, and you might be surprised: a ‘tricorder’.

Photos

View photos

Related Categories

From this Section

FEATURE

“It is the ultimate device which not only gives you all the data you want, but also assist you in diagnosis,” he explains.

For those not in the know, a ‘tricorder’ is a handheld scanner wielded in the classic American science fiction series Star Trek.

Dr Low is not alone. Medical administrators throughout the region are looking to marry device processing power with portability. “Mobility is definitely the way to go because they enable doctors and nurses to work at the bedside,” agrees Pascal Tse, CIO of Hong Kong’s St Teresa’s Hospital, a 640 bed modern hospital serving the population of Kowloon.

Before, nurses had to take notes on paper and keyed in the information when they returned to their workstation. Likewise doctors had to bring bulky medical records in paper format while doing rounds. The drawback, as highlights Tse, was that the paper was easily lost or mixed up with that of another patient’s which was dangerous.

“Not only was a substantial amount of time spent on travelling back to collect notes, but this approach was also error prone,” comments Joseph Ho, CIO of Taiwan’s Chang Gung Memorial Hospital (CGMH). “If we allow input of and access to information right at the bedside, both patient safety and service quality will be dramatically improved.”

Established in 1978, CGMH now manages five major hospitals in Taiwan, with a total capacity of 8600 beds.

“Mobility brings value because you can measure, chart and plan at the bedside,” concurs Dr Wong Merng Koon, Co-Director for Trauma Service and Senior Consultant at the Department of Orthopaedic Surgery, Singapore General Hospital (SGH). “Otherwise you will be looking at all the numbers and trying to derive a chart in your mind, which is uncertain and error prone.”

Dr Wong’s expertise in IT makes him an advisor to the IT department of the 1467-bed hospital, Singapore‘s largest.

“There are many options for mobility, with each having their pros and cons,” comments Dr Low. “We need to match each of the devices with end users and specific functions of each job.”

Upwardly mobile. Among these options, the simplest is PDA type of devices, widely used by nurses for drug administration. The PDA sends out alerts when a drug is due to be applied. The nurse then comes to the ward, scans the barcodes on both the drug bag and patient’s wrist band before applying the medication. Combing the scanning and alert functions, these devices ensure the right medication is applied to the right patient at the right time.

Having ruggedised PDAs with scanner deployed for a couple of different functions, Saint Teresa’s Tse says the handy units are giving confidence to frontline users.

Another important application of PDAs is to capture vital signs and other measurements, such as blood sampling and body temperature. “This dramatically improves nurses’ workflow,” comments Tse. In addition, if the doctor comes by and asks for the latest information, nurses will have that right at the fingertip.

Similarly, workflow is further improved when data captured can be directly transmitted to the relevant laboratory for analysis, cutting the need for the sample to travel and preventing the error which might ensue.

It’s not only the medical signs which can be captured. CGH uses PDA devices to take patients’ dietary orders, explains Dr Low. Nurses go to the ward to take the order, which is instantaneously transmitted to the kitchen via the wireless network.

However, that is currently the limit of what PDAs can achieve. Tse notes that when it comes to EMR access, PDAs have many limitations.

CGMH’s Ho implemented PDAs for medical record access a few years ago. And after two years of trial, he was convinced that it was not the way to go. “The screen is very small,” he notes that for clinicians, the problems of PDAs compensate its advantages. “When the doctor wants to have a full view of the information, he has to scroll up and down, left and right.”

“Scrolling is a big issue here,” concurs Dr Low of CGH.

Also battery life is a concern to many, including S Teresa’s Tse: “Since it’s in the pocket most of the time, people tend to forget to charge it, until the device is out of power.”

Charging brings yet another problem. “It is very easy for a by-passer to steal the device left on the nursing station for charging,” comments Ho. “And when you are responsible for the device’s loss, chances are you are not going to use it.”

In fact it was discovered at CGMH that fearing such a loss, many nurses preferred to lock their PDAs in the drawers and reverted to taking notes with paper and pen.

Ho was also concerned about the extra effort to customise the existing software applications for use on PDAs. Since CGMH develops all its applications, the redesign would put massive pressure on the hospital’s IT team.

“At the end of the day, PDAs have very limited scope,” comments Dr Low. “Again the biggest constraint is its screen size; and many sisters and senior doctors find itvery uncomfortable reading small prints.”

Portable tablets. Since screen size is the major concern here, how about a device with much bigger size and yet portable?

“Medical-scale tablets can be very successful,,” comments Andy David, SAP‘s Industry Principal for Healthcare. “They are a compromise between the desire of large screen and space constraint.” CGH has deployed such computers in its Accident and Emergency Department.

These units come with all the necessary accessories and features, says Dr Low, including medical record access, barcode recognition and Bluetooth connectivity.

Yet portable, tablets have a real advantage in areas such as ICU where space constraint disallows pushcart-mounted computers. Dr Low also reveals that it is much easier for a group of doctors to carry a tablet while doing team-based rounds. Dr Low says the feedback from doctors is very positive.

Another plus point is when the doctor is holding a medical scale tablet; they look just as in old times where their predecessors held paper on a clipboard. This makes patients more comfortable because doctors don’t turn away from them while working with the computer.

But again, battery can be a problem. SGH’s Wong expects tablets to work for eight hours – one whole shift – without recharging. However, he says that this long battery life is not yet available with a screen which is big enough for doctors to use and at the price point that hospitals can afford for mass deployment.

He also dismisses handwriting recognition in clinical setting. “Data is only useful when machine can read it,” he says. “Not only is handwriting recognition very bad, it also requires doctors to use a very precise lexicon for machine to understand. But doctors are used to describing the same problem in different ways.”

Dr Low concurs: “They are suitable for ticking boxes and typing. When you write you will notice that you actually spend more time correcting mistakes.”

CGMH‘s Ho also evaluated handwriting recognition of tablets and found out it is a bigger problem for them since some of its doctors take notes in Chinese. “We decided to abandon that proposal in the end.”

Although at 1.5 kg, these tablets are much lighter than conventional laptops, carrying it for long is still a tiring job. Dr Low has noticed that nurses prefer to tuck the unit close to their body, instead of holding it in the arm as the vendor recommended. “We have to think about carrying strap or other aid for each of the units,” he says.

BEDSIDE TERMINALS. Another option, which saves clinicians the hassle of carrying (or pushing) their mobile devices, is to install fixed computing terminals at the bedside. Such a terminal also provides patients with entertainment options. “Doctors only do their round maybe twice a day, and use the system for 10 minutes each time,” says SGH’s Wong. “For the rest of the 24 hours, the terminal is with the patient.”

At SGH, there are 20 such terminals for patients to surf the internet, watch TV as well as make phone calls and video conferences via Skype. “It’s perfect for those who want to keep a close eye on the stock market while in the ward,” Wong jokingly says.

When the doctor is doing his rounds, he will temporarily suspend the entertainment and switch the system to the medical mode. This is achieved quickly through a smart card; and when the card is withdrawn, the system returns to the patient’s entertainment mode.

While deployed many hospitals in Europe, cost is prohibiting bedside terminals’ prevalence in Asia. “The thin client itself is not expensive,” Wong explains. “However, it is very difficult to recover the cost of the whole infrastructure.”

GETTING THE MESSAGE THROUGH. In addition, several hospitals in Singapore have deployed a mobile messaging system for non-emergency communications between doctors, nurses and patients.

The system is integrated with the clinical management suite and users, typically doctors, could send notifications in text messages via their mobile phone or a web portal. The system also automatically generates alerts for the users.

While also thinking about such a system, Dr Low points out that a lot of rules need to be set to make sure the system functions correctly and securely.

And the above list is not exhaustive, obviously different options are for different user groups in different functions within a hospital. As St Teresa’s Tse points out, hospitals need to optimise different deployment to ‘get the best benefits out of mobility’.

“We should do our feasibility studies, look at the workflow and needs of different user groups,” Dr Low says. “Many other factors need to be put into consideration.”

WHO ARE YOU? Also for mobile devices to work at the bedside, correct identification of patients is crucial. “All these mobile tasks require very clear patient identification,” notes Tse. “Technologies such as barcode and RFID go hand in hand with mobile solutions; otherwise your mobile projects won’t be successful.”

“Co-existing with barcode, RFID is currently viable for special operations,” says David. “When the technology becomes more mature with lower cost, it will be more prevalent.”

RFID technology is currently deployed in three functions areas of the CGMH, including operating theatres, psychiatric ward and baby rooms. Ho explains that this implementation is based on the needs: “Patients on the operating theatre are treated with anaesthetic and can’t speak; all the new born babies look similar and might be easily mistaken; and psychiatric patients need close monitoring so that they will not hurt themselves and others.”

While looking at the opportunity of expanding RFID to other areas, Ho stresses that for scenarios where barcode and RFID are able to deliver the same result in terms of administration and quality, barcode will be adopted purely for the simplicity and lower cost of development and maintenance.

SOFTWARE PLATFORM. David also points out that ‘fundamental components’ – software applications such as patient management system – need to be ready for any mobile solution to be rolled out.

Tse adds that VPN and firewall are also parts of this infrastructure hospitals need to build before embarking on a mobile journey.

And software can also be a challenge for hospitals who are already venturing into mobility. “For this whole range of devices to function and to interoperate, we are still trying to resolve the compatibility issue with the EMR system,” says Dr Low. “After this is resolved we will see a big takeoff of mobility.”

Dr Wong says that for drug administration, computers are still not intelligent enough to understand the nuances. For instance, when the doctor prescribes the medication for three months, but the current month has 30 days and the next has 31. Current computer system will not be able to make a correct decision.

Also, if the computer is programmed to apply certain drug at 6pm, error will be given if nurse tries to do that at 5:55pm.

BACK TO THE FUTURE. Looking forward, Ho would like to extend mobility beyond hospitals’ premises into the community. “In case of emergencies, if we can work on the ambulance and even at the scene, the time saved would be crucial,” he notes. “To achieve that we need to make use of the public network and rethink about the security.”

A few hospitals in Taiwan are already leveraging the public WiMAX network for healthcare services in the community and in ambulances. [FutureGov 5.4 July/August 2008 page 40]

Dr Wong is interested in a translucent display which could potentially solve the dilemma of comparing medical images with limited screen space – “just like Da Vinci who paints two images on the same canvas.” However, as he points out, an affordable translucent system designed for clinical use is yet to emerge.

While Dr Low, who dreams for tricorder, a device which frees doctors’ hands is enviable. “I would eventually want all of us to be able to work with earphone, to give orders through a voice jack into a system that recognises my voice and executes the order,” he elaborates.

“Every piece of information will be at my fingertips that I can see, without plugging in and out lots of funny things.”

Dr Low also hopes that instead of just documenting, displaying information and taking orders, mobile devices with have built-in artificial intelligence which enables them to make accurate diagnosis – thus become a really close friend to the doctors.

So the futuristic ‘tricorder’ is not it seems such a distant dream. Perhaps in a decade’s time, Chief Medical Officer ‘Bones’ of the Starship Enterprise might be envying what hospitals on the Earth are using.